Addressing Absenteeism and Enhancing Performance in Uganda’s Health Sector
Health workers who fail to fulfill their duties are facing disciplinary actions, as emphasized by Dr. Diana Atwine, the Health Permanent Secretary. She criticized those who believe that being on call means only responding to emergencies at health facilities. “We took the Hippocratic oath to be available for patients regardless of the circumstances,” she stated.
Dr. Atwine also highlighted the need to address health workers who report for duty but spend excessive time on social media instead of focusing on patient care. She urged facility heads to prioritize monitoring and measuring staff performance effectively.
The revised Uganda Public Service Standing Orders from 2021 provide a framework for managing public service employees, including health workers. These orders cover conduct, discipline, and terms of service. Key areas include professional conduct, patient confidentiality, and prohibitions against bribery. Additionally, the Ministry of Health has established service standards and a comprehensive health service manual to guide quality service delivery.
“If every health worker adhered to the standing orders and job descriptions while conducting community health outreach, the country would see significant transformation even with limited resources,” said Dr. Atwine.
The Health Ministry’s director of Public Health, Dr. Daniel Kyabayinze, emphasized the importance of evaluating individual performance and key outputs for each health worker. He mentioned that supervisors must submit monthly reports to the Director General of Health Services regarding days worked and any challenges faced.
Dr. Alfred Driwale, commissioner for Institutional and Health Workforce Development, noted that absenteeism in local governments is the responsibility of chief administrative officers. He warned local governments not to tempt the central government to take action against absenteeism.
Ideally, lower health facilities should have at least two clinical officers on duty simultaneously to reduce patient waiting times. However, some facilities use a duty roster where a clinical officer works for two weeks and then disappears for the same period.
Dr. Atwine also criticized senior medical officers who delegate very sick patients to junior health workers who cannot make critical decisions, leading to unnecessary referrals. For example, a health centre IV with a theatre and doctor may refer a mother with a severe tear to a larger hospital, causing delays and potential harm.
She urged health workers to ensure effective referral systems based on strong justifications. This discussion took place during the commissioning of the refurbished Bulamagi HC III in Iganga district and the closure of a health systems strengthening project focused on reproductive, maternal, newborn, child, and adolescent health services in Busoga region.
Bulamagi HC III was refurbished with support from the Ministry of Health, World Health Organisation, and the Government of Korea. The five-year project, costing sh$10 million, was implemented across five districts in Busoga region: Bugiri, Kamuli, Iganga, Mayuge, and Buyende.
WHO representative in Uganda, Dr. Kasonde Mwinga, highlighted that the refurbished facility will help save mothers and newborns during deliveries. However, the implementation of biometric instruments remains incomplete.
Dr. Alfred Driwale explained that biometric machines are not present in all health facilities. While technology can aid in solving issues, more interventions are needed for effective implementation, monitoring, rewards, and sanctions. Currently, the focus is on investing in infrastructure, including biometric machines and computers, but more is required for national coverage.
Biometric machines use unique biological characteristics such as fingerprints, facial features, iris patterns, or voiceprints to identify individuals. They are commonly used for security, access control, and attendance tracking.
Health Workers’ Perspectives on Biometric Systems
Kamuli district health officer Dr. James Wako shared that they use a duty roster tallied with daily attendance records. Every month, an analysis is conducted and fed into the human resource management system. Health workers not meeting expectations are invited for hearings, and effective supervision ensures improvement.
Errant workers face sanctions, and if the issue persists, it is escalated to the Chief Administrative Officer. Indiscipline often results in no pay. Dr. Wako noted that they use a manual registration system because biometric finger machines were not installed in health facilities.
Dr. Patrick Kitimbo, the district health officer for Iganga, mentioned that the biometric machine at Iganga General Hospital has been non-functional for six months. In the meantime, health workers use a book to sign in and out of their duty attendance.
Dr. Wako suggested that biometric machines could be more effective if they captured both fingerprints and faces. Currently, the machines only capture fingerprints, allowing manipulation to register absent workers.
Lira district health officer Dr. Patrick Buchan Ocen noted that biometric machines are only present at Lira regional hospital, not in lower health facilities. However, the introduction of a human resource management attendance system by the Ministry of Health has improved attendance rates.
According to Dr. Buchan, the system allows each health facility to upload the duty roster, with daily attendance recorded by the in-charge. District health officers can monitor who worked for the day, and mid-month, they can identify those who worked at least 15 days. Those working fewer than 15 days have their salaries withheld, and they are sanctioned to explain their absence.
Dr. Buchan observed that after salary withholding, health workers’ attendance improves the following month. Before this system, the situation was dire, with some officials working only two days a week. On days when the district health team conducted monitoring, everyone was present.